Lower urinary tract symptoms in elderly men: Considerations for prostate cancer testing.

PURPOSE: Both lower urinary tract symptoms (LUTS) and prostate cancer (PCa) are common in elderly men. While LUTS are generally due to a benign etiology, they may provoke an evaluation with prostate-specific antigen (PSA), which can lead to a cascade of further testing and possible overdiagnosis in patients with competing risks. There is limited patient and provider understanding of the relationship between LUTS and PCa risk, and a lack of clarity in how to evaluate these men to balance appropriate diagnosis of aggressive PCa with avoidance of overdiagnosis. METHODS: A literature review was performed using keywords to query the electronic database PubMed. All articles published before November 2023 were screened by title and abstract for articles relevant to our subject. RESULTS: Epidemiological studies suggest that LUTS and PCa are largely independent in elderly men. The best available tools to assess PCa risk include PSA permutations, novel biomarkers, and imaging, but there are limitations in older men based on lack of validation in the elderly and unclear applicability of traditional definitions of "clinically significant" disease. We present a three-tiered approach to evaluating these patients. CONCLUSION: Elderly men commonly have LUTS as well as a high likelihood of indolent PCa. A systematic and shared decision-making-based approach can help to balance objectives of appropriate detection of phenotypically dangerous disease and avoidance of over-testing and overdiagnosis.

Less qualitative multiparametric magnetic resonance imaging in prostate cancer can underestimate extraprostatic extension in higher grade tumors.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) is increasingly used for risk stratification and preoperative staging of prostate cancer. It remains unclear how Grade Group (GG) interacts with the ability of mpMRI to determine the presence of extraprostatic extension (EPE) on surgical pathology. METHODS: A retrospective review of a robotic assisted laparoscopic radical prostatectomy (RALP) database from 2016-2020 was performed. Radiology mpMRI reports by multiple attending radiologists and without clear standardization or quality control were retrospectively assessed for EPE findings and compared with surgical pathology reports. The data were stratified by biopsy-based GG and a multivariable cluster analysis was performed to incorporate additional preoperative variables (age at diagnosis, PSA, etc.). Hazard ratios were calculated to determine how mpMRI findings and radiographic EPE relate to positive surgical margins. RESULTS: 289 patients underwent at least one mpMRI prior to RALP. Preoperative mpMRI demonstrated sensitivity of 39.3% and specificity of 88.8% for pathological EPE and had a negative predictive value (NPV) of 49.5%, and positive predictive value (PPV) of 84.0%. Stratification of NPV by GG yielded the following values: GG 1-5 (49.5%), GG 3-5 (40.8%), GG 4-5 (43.4%), and GG 5 (30.4%). Additionally, positive EPE on preoperative mpMRI was associated with a significantly decreased risk of positive surgical margins (RR: 0.655; 95% CI: 0.557-0.771). CONCLUSIONS: NPV of prostate mpMRI for EPE may be decreased for higher grade tumors. A detailed reference reading and image quality optimization may improve performance. However, urologists should exercise caution in nerve sparing approaches in these patients.

Less qualitative multiparametric magnetic resonance imaging in prostate cancer can underestimate extraprostatic extension in higher grade tumors

ABSTRACT Background: Multiparametric magnetic resonance imaging (mpMRI) is increasingly used for risk stratification and preoperative staging of prostate cancer. It remains unclear how Grade Group (GG) interacts with the ability of mpMRI to determine the presence of extraprostatic extension (EPE) on surgical pathology. Methods: A retrospective review of a robotic assisted laparoscopic radical prostatectomy (RALP) database from 2016-2020 was performed. Radiology mpMRI reports by multiple attending radiologists and without clear standardization or quality control were retrospectively assessed for EPE findings and compared with surgical pathology reports. The data were stratified by biopsy-based GG and a multivariable cluster analysis was performed to incorporate additional preoperative variables (age at diagnosis, PSA, etc.). Hazard ratios were calculated to determine how mpMRI findings and radiographic EPE relate to positive surgical margins. Results: Two hundred and eighty nine patients underwent at least one mpMRI prior to RALP. Preoperative mpMRI demonstrated sensitivity of 39.3% and specificity of 88.8% for pathological EPE and had a negative predictive value (NPV) of 49.5%, and positive predictive value (PPV) of 84.0%. Stratification of NPV by GG yielded the following values: GG 1-5 (49.5%), GG 3-5 (40.8%), GG 4-5 (43.4%), and GG 5 (30.4%). Additionally, positive EPE on preoperative mpMRI was associated with a significantly decreased risk of positive surgical margins (RR: 0.655; 95% CI: 0.557-0.771). Conclusions: NPV of prostate mpMRI for EPE may be decreased for higher grade tumors. A detailed reference reading and image quality optimization may improve performance. However, urologists should exercise caution in nerve sparing approaches in these patients.